As you are aware, CPT changed the guidelines for coding evaluation and management services in the office setting effective in 2021. This presentation will review the changes in code selection requirements. Some of the key changes in the guidelines are that history and examination are no longer used to determine the level of service. While it is still necessary to document a medically appropriate history and examination, specific components are no longer required for coding purposes. Medically appropriate is determined by the provider. That means that the level of service is based solely on either medical decision making or time. The provider has the choice of which method to use. The requirements for time-based coding have also changed. Counseling no longer has to make up 50% of a visit to assign the service level using time. Time now includes all time spent personally by the physician on the date of the encounter. Let's take a look at the details, starting with medical decision making. The requirements for each level of service are listed here. An increase with each code level from straightforward to low to moderate to high. Let's take a look at how calculating medical decision making has changed. Using the old 95 or 97 guidelines, medical decision making had a points system. You counted points for presenting problem and data and consulted the table of risk for risk level. Two out of the three components were required to reach the same level of service in order to build that level. The new 2021 guidelines still have three components, but problems addressed is no longer calculated with a point system. Two out of three components are still required to meet the level of service. To recap, medical decision making in the 95-97 guidelines included nature of presenting problem, data to be reviewed, and risk. Though similar, there are some distinct changes in the 2021 guidelines, which now require the number and complexity of problems addressed, assessing and reviewing data, and risk. In the old 95-97 guidelines, nature of the presenting problem was calculated using points, with four points being high complexity. Under this method, points could be added so four stable established problems reached high complexity. This factor was important with two components needed to determine the service level. In the new 2021 guidelines, problems addressed are listed in chart form, much like the old table of risk. Points are not added together, so two or more stable chronic conditions qualify as moderate complexity. This differs from the 95-97 guidelines, where four stable conditions reach high complexity. It should be noted that the presence of a condition listed in the patient's record or managed by another provider does not qualify as being addressed. Also, the AMA-ENM guidelines indicate that only diagnoses documented as active treatment during the encounter will be credited for scoring purposes. Here is the table of problems addressed for 2021. As you can see, there are no points to be added. The level is chosen based on the type of problem addressed. Under the old 95-97 guidelines, the list of possible data points was added to determine the level of complexity. This list provides some examples of how points could be added. Note, all labs were grouped together, so you only got one point for labs, no matter how many unique tests were reviewed. The new 2021 guidelines divide data into three categories – tests, independent interpretation, and discussion with external physician. The new 2021 guidelines still count components to determine the level of service, but several things are different. Each unique test counts as one point. For high complexity, two out of the three components must be completed. In the 95-97 guidelines, risk was determined using this table. Only one component of risk was necessary to reach the level of service. Since the table is small, the next few slides give a clearer picture of what qualified as moderate and high risk using the 95-97 guidelines. Starting with the Presenting Problem Risks, the Diagnostic Procedure Risks, and the Management Option Risks. For 2021, the last medical decision-making element is risk, which includes the risk of complications, morbidity, and or mortality of patient management decisions made at the visit. This includes treatment options considered but not implemented. For example, a decision about hospital admission would increase the level of risk. Examples are given as a guide, and the 95-97 table has very similar examples, so it can also be used as a starting point. Here are the examples given for the level of risk using the 2021 guidelines. Here is the entire medical decision-making table. Note again the two out of three component requirement to reach the service level. To recap some of the key differences, since the new guidelines do not add points for problems addressed, multiple chronic stable illnesses do not reach high complexity. Data points now have three components, and high complexity requires two out of three. The 95-97 guidelines only allow for time to be used to determine the level of service when counseling or coordinating care took up 50% of a visit. Physician had to include both time and what was counseled or coordinated. Using the new 2021 guidelines, counseling is no longer the only factor. Any visit can be documented based on the total time spent on the date of the encounter. Time can include activities both before and after the actual visit, as long as they are performed by the physician on the date of the encounter. Time spent must be documented in the chart note in order to bill based on time. The 2021 guidelines also include time ranges for each level of service, so there is no rounding or guessing to determine if the service level is met.

coding evaluation and management services

guidelines

office setting

2021

medical decision making